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FOROFFIC5YUE: 1k, _______ ___________ _____________________-.._____._.- APPLICATION FOR SANITATION PERMIT Permit No. _14.1........... --------------------------------------------------------- (Complete in Duplicate) ----- This Permit Expires 1 Year from Date Issued -� Date Issued : ..fit :.:........ a Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County rdina ctNo. 549. JOB ADDRESS AND LOCATION--•------_-------------- --- � - 31 ':g Owner's Name__ u- r !:--- - ...... -------------------------- Phone-------._._._._.__._............... Contractor's Name...-:Yr�-------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: /---- Number of bedrooms __- Number of baths -,-*___ Lot size ............................................................ Water Supply: Public system A4 Community system ❑ Private ❑ Depth to Wafer-Table ........ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay I] Adobe Rf Hardpan ❑ Previous Application Made: (If yes,date____________________) No a New Construction: Yes ,V No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance fro foundation___ _'+___.Material__ - - ,..-•.--., Li uid dt e h_____ _____ _ Ca aci ......Sizea > q I? ��- P +Y est' A� No. of compartments Disposal Field: Distance from nearest well-----------------Distance from foundation._ }-----Distance to nearest lot line_.- J Number of lines----------- Length of each line_ s'� ' . i'dth of trench_______' Type of filter material.-.-,-41 .__Depth of filter material____. ' !.__Total length---A.*------------------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line................. ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------ .-- Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation---------------------Lining material.............................:....... ❑ Size: Diameter------------------------ ---------Depth----------------------------------------------------Liquid Capacity---------••-----•-•-......gals. Privy: Distance from nearest well------------------------------------------------- from nearest building.......................................... ❑ Distance to nearest lot line------------------------•-------------------•------•-•----•----------._._......- Remodelingand/or repairing (describe)-------------------------------------------------------------------------------------------------------------.-----------------------------------•......... --------------------•-•--• • ---- , I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)--- k�� -f (Owner end/or Contractor) li By:--------------------------------------------------_------------------------------------------------------------------.-------------(Title)-----------------------•---------------- -------------------•- (Pio+ plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY � r -------------------------------------------------- DATE--- REVIEWEDBY... ------ ----------------------------------•----••-------------- DATE-------------- BUILDING PERMIT ISSUED........-•------- --------- - r --------- D TE ----- --• - -------- A Alterations and o ecomme ations:-__ . - ...� ... 8i! ••- --------------------------•-----•-•----------•------------•---•--•-•-•----------------•---------------------------------------- ...-------••----------------------------•------•-------------------•---------.....---------- ----------------------------------- ------------------------------ ------- -------------------------------•---•-----••-•-----------•---------------•-------•---•--- ----------- ---•-••--------------------•----------- ` � FINAL INSPECTION BY:.---.- -�----- - Date_________ _____ ___I - G -------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Srreet 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California ES 9 REVISED S.59 2M 5.61 ATLAS